1. Improving Hand Hygiene after a Cerebral Vascular Accident
Elizabeth Carr October 2016 Stroke Specialist Nurse

2. The Black Hole Literature about hand washing of patients is scant
There is even less information on care of finger nails
Many agencies and NHS discourage staff from cutting finger nails and suggest referral to podiatry
Great confusion (podiatry don't cut finger nails either)

3. 5 Key Points Hand washing and nail care are basic, but essential task
Spasticity after a neurological diagnosis can make opening the hand difficult
Clear care planning and a consistent approach to hand care are needed
Specialist training to improve confidence and skill in this area
Commissioned care should include time for this task to be carried out as part of holistic intervention

4. What is spasticity ?
Spasticity is a symptom of upper motor neurone damage. Muscles involuntarily tighten and, in the upper limb, a common pattern is of a flexed elbow, flexed wrist and clenched hand and fingers.
If not managed correctly, the tight muscles of spasticity can cause problems.

5. Spasticity Problems Difficulty opening the hand
Clenching causing pressure areas between the fingers or on the palm
Changed nail growth
Muscle shortening
Hypersensitivity
Pain
These problems can lead to eventual changes in the joints and tendons(Bandi and Ward,2010).

6. Duke L et al (2015)
Suggested that caring for hands tightened by spasticity after a stroke ,brain injury or other neurological conditions can be challenging for care staff.
Opening and cleaning the hand ,managing pressure areas, cutting nails and reducing pain become more complex if muscles are tight and short
Hand hygiene is key for staff but literature on patients hand and nail care is lacking.

7. Role of Care Staff
Health professionals hand-washing compliance is globally accepted as the most important procedure in preventing infection.
(National Institute for Health and Care Excellence,2014;Dougherty and Lister,2011)
That means our patients hands too.

8. The Importance of hand hygiene
Good skin care involves four processes being carried out on a regular basis:
Cleaning
Hydrating
Protecting
Replenishing (Voegeli,2008)
Absence of any one of the processes increases the risk of skin damage

9. Factors affecting hand care
Pain
Anxiety
Limited communication and understanding
Cognitive impairment
Lack of inhibitory control
Overstimulation
Mental health issues(Bowers,2010).

10. Basic hand care advice Explain procedure
Gain consent or establish that what you are doing is in the patient`s best interest
Visually inspect the hand for any skin/nail damage
Report any problems to nurse in charge/line manager/inform GP.
These may include; skin breaks, maceration, fungal infections,ingrowing nails, thickened nails or exudate.

11. Washing Hands
Do not force the hand open or move the finger quickly. Use slow, but firm movements.
Immerse in a basin /bowl of warm soapy water (check temperature first)
The use of non-perfumed aqueous cream can help to lift any dried/dead skin or use hand wipe
You may need two people if the hand is very tight-one to hold the hand and distract the patient and one to wash

12. Washing Hands
Dry the hand thoroughly (using clean towel or paper towel)
Apply hand cream if the patient wishes and has no relevant allergies
Document and report what you have done and any problems encountered

13. Keep nails short
If the patient has a diagnosis of diabetes, rheumatoid arthritis, HIV, or is prescribed anticoagulation medication, do not start nail care without discussing the patients care plan with the nurse or doctor /manager in charge.
Perform regular nail care
Visually inspect the nails and surrounding skin, check under the nails
Clean under the nail

14. When possible, use single-use nail file or disposable emery board to keep nails short; this reduces need for scissors
Shape and shorten the nail following natural shape
Dispose of, or clean any equipment used
Document and report what you have done.
Before using scissors training in general nail care is required and needs to be discussed with line manager

15. Stretching the hand
Needs to be discussed with the occupational therapist or physiotherapist
You need to be competent and confident
Identify training needs
If competent and stated in care plan
Continue
Take your time

16. Stretching the hand
Gain consent or act in best interest and as care plan
Open the hand slowly
Use techniques (as trained) for example gently
bending the wrist to gain more access to the palm of the hand
Carry out stretching/opening of the hand regularly
Use hand splint/palm protectors, if provided, for the recommended time scale
Monitor the fit, observing for pressure ulcers, reporting any problems to person in charge
Hold the hand open with other options, for example a roll of bandage
Do not force the hand open or move fingers quickly
Do not allow the hand to be unopened for a long period of time

17. Remember
If in doubt give the stroke team a shout Base: Crompton Health Centre Telephone:

18. Any questions